What Is Metastatic Breast Cancer?

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Learning that your breast cancer has spread to another part of your body can understandably cause tremendous fear and uncertainty. But there are effective treatment options for metastatic breast cancer, and many women find that these treatments effectively control their cancer with relatively few side effects, and a good quality of life as well.

Doctors assign stages to breast cancer based on the size and location of the tumor, whether lymph nodes are involved and whether the cancer has spread beyond the breast. Early stage breast cancer is classified as either stage I or II, depending on the size of the tumor and whether any local lymph nodes are involved. "Locally advanced breast cancer" is considered to be stage III and describes either a large primary tumor or one that has invaded the chest wall (skin, muscle and/or ribs) and/or the lymph nodes near the breast, around the collar bone or in the armpit.

Metastatic breast cancer is also called late stage, which is considered to be stage IV. Metastatic breast cancer describes a cancer that has spread from the original tumor site in the breast to another part of the body. A metastasis occurs when cancer cells break off from the primary tumor and move through the bloodstream or lymph system to other organs such as the brain or the bones.

How Is Metastatic Breast Cancer Diagnosed?

When breast cancer first develops, you may not notice any symptoms. As cancer progresses, however, it can cause changes in and around your breast, including:

A lump or thickening in or near the breast or under the arm

Change in the size or shape of the breast

Discharge from the nipple or tenderness at the nipple

A nipple pulled back into the breast

Ridges, dimpling or pitting in the breast (skin looks like an orange peel)

Changes such as redness, warmth, ulceration, scaly or swollen skin on the breast, nipple or the colored area around the nipple, called the areola

At times, newly discovered breast cancer has already spread to distant organs in the body and is diagnosed as stage IV breast cancer. This may mean that the cancer was present and slowly growing for a long time before it was detected, or it may mean that the cancer has grown rapidly in a short time.

Some women are diagnosed with breast cancer at an earlier stage, receive treatment and go into remission, only to find later that their cancer has returned to the same or a different breast or to some other part of the body. Metastatic breast cancer most commonly spreads to the bones, liver, lungs or brain.

The symptoms of metastatic breast cancer depend on the size and location of the metastasis. If your breast cancer has spread to your bones, for example, you may experience bone fractures or generalized pain in your bones. Cancer that spreads to the lungs may cause shortness of breath, and abdominal pain, swelling or yellowing of the skin (jaundice) may indicate liver metastasis. Headaches, seizures or related symptoms could indicate spread of cancer to the brain.

If you experience any of these symptoms and you are already under the care of an oncologist, your doctor will order additional imaging tests, such as computed tomography (CT, or CAT, scans) and magnetic resonance imaging (MRI), Ultrasounds, PET scans or additional lab tests to get a definitive diagnosis.

What Is Bone Metastasis?

Bone metastasis occurs when breast cancer cells break off from your original tumor and spread to your bones. This is not the same as primary bone cancer, a form of the disease that begins in the bone. Bone metastasis is a serious complication of breast cancer that can weaken your bones, cause pain or fractures, and make it difficult for you to continue activities you enjoy.

While people with many different advanced cancers have bone metastasis, it is more likely to occur in patients with breast cancer. About three out of four women with advanced breast cancer eventually develop bone metastases.

Sometimes doctors find bone metastasis when they first diagnose the primary breast cancer. At other times, they find it months or years later, or during follow-up tests. If your doctor suspects you have bone metastasis, he or she will order imaging tests, such as X-rays, bone scans, CT scans and MRIs. They will also order blood tests to look for high levels of substances that are released by cancer cells or by damaged bone, and they may do a biopsy to take a tiny amount of tissue for study under a microscope.

Symptoms of bone metastasis may include:

Pain in a bone: This is often the first symptom. The pain may come and go and feel worse at night.

Broken bones (fractures): Most often fractures related to bone metastasis occur in the bones of the arms, legs and spine.

Back pain and numbness in the legs: Cancer that spreads to the spine can put pressure on the spinal cord. This causes pain and can cause numbness and even paralysis in the legs.

Metastasis to the Liver, Lungs and Brain

Breast cancer most commonly spreads to the bones, but it also can metastasize to the liver, lungs, brain or other organs. Once you’ve had breast cancer, it’s important to pay attention to any new symptoms you experience that may indicate that your cancer has spread outside of the breast.

Symptoms of liver metastasis may include:

Abdominal pain or bloating that continues for an extended time without any obvious cause

Yellowing of the skin or eyes (jaundice)

Abnormal liver function blood tests

Weight loss or loss of appetite

Symptoms of lung metastasis may include:

A persistent cough that gets worse over time.

Shortness of breath

Unexplained chest pain

Weight loss or loss of appetite

Symptoms of brain metastasis may include:

Headaches

Seizures

Blurry or double vision, or loss of vision

Confusion or personality changes

Dizziness, balance difficulties or frequent falling

Nausea and vomiting

Your doctor may order imaging and lab tests to determine if your symptoms are caused by a recurrence or spread of your breast cancer. These may include:

Blood tests, including white blood cell and platelet counts, to look for signs of cancer.

Imaging studies, including:

X-rays

MRI

CT scan

Ultrasound

Removing a small sample of tissue (biopsy) or fluid from the affected area and looking at it under a microscope for cancer cells.

How Is Metastatic Breast Cancer Treated?

Once your breast cancer has spread from the original tumor site to other parts of the body, it is more difficult to treat. And in the past, it would generally have been considered incurable. That may be changing, however, as new treatments for advanced breast cancer are allowing many patients to live longer, healthier lives. Therapies are constantly evolving, and researchers continue to refine treatments and make them more effective with fewer side effects.

The goals of treatment for metastatic breast cancer are to stop the progression of the disease, prolong a patient''s life and, most importantly, to maintain or improve quality of life by relieving symptoms and minimizing side effects from the treatment.

Treatment options depend on where the cancer has spread and may include both general and specific therapies that are tailored to the cancer type, location and symptoms as well as to your personal situation.

How Is Surgery Used to Treat Metastatic Breast Cancer?

Until recently, surgery was not considered a viable option for metastatic breast cancer. However, this may be changing in certain situations. A 2005 study at the University of Geneva found that even if a woman''s cancer has already metastasized by the time she was initially diagnosed with breast cancer, her chances of survival were greatly increased after surgery to remove the primary tumor.

The study followed 5,000 women who had been diagnosed with breast cancer beginning in 1970. In the 300 women in that group whose breast cancer had already metastasized at the time of diagnosis, the researchers found that if a primary tumor had been completely removed with clear margins, those women were 40 percent less likely to die from their breast cancer. Even those whose breast cancer had spread to the bones had an 80 percent chance of survival after five years if they had had surgery.

Sometimes surgery is used to treat cancer that has spread to the bones. The goal of this type of surgery is to relieve pain as well as to stabilize a weakened bone and reduce the risk of fracture. During surgery, doctors insert a metal rod into the bone or use an external device to stabilize the bone and allow the patient remain active. If cancer has spread to the bones of the spine, there is a risk that it may compress the spinal cord and lead to paralysis. In this case, prompt surgical intervention can relieve this pressure as well as provide pain relief.

Surgery can sometimes be used if the metastasis is small and localized, such as an isolated metastasis in the liver, lung or brain (these may be treated with radiation instead).

How Is Radiation Used to Treat Metastatic Breast Cancer?

Radiation Therapy

Radiation therapy, also called radiotherapy, uses high-energy rays to kill cancer cells. Patients who have had breast cancer surgery, especially those who have had breast-conserving procedures, sometimes also undergo radiation therapy to destroy any remaining cancer cells. Your doctor may suggest radiation therapy before surgery to destroy cancer cells and shrink tumors.

Radiation is also often used to shrink tumors and slow the progression of cancer that has metastasized, and to reduce pain or treat other symptoms related to the spread of cancer.

Stereotactic radiosurgery using a machine called a Gamma knife is a focused form of radiation therapy to treat brain tumors including metastatic breast cancer. This type of radiation precisely targets the tumor using CT or MRI scans and focuses radiation beams at the tumor from hundreds of different angles for a short period of time. It’s often used to slow the growth of small (less than 4 centimeters), deep, or well-defined tumors that are hard to remove surgically.

Which Hormonal Therapies Are Used to Treat Metastatic Breast Cancer?

In some women, the natural hormone estrogen makes breast cancers grow, and reducing the amount of estrogen to which these tumors are exposed has been found to prevent or slow the growth of the cancer. Breast cancers fueled by estrogen are called hormone (or estrogen) receptor-positive cancers. One type of treatment for such cancers is so-called hormonal therapy. Doctors can determine whether you will benefit from this type of treatment by measuring the estrogen and progesterone receptors on your tumor.

Research has shown that newer hormone therapies tend to have fewer side effects than chemotherapy, and seem to control metastatic disease just as well as or better than more aggressive treatments.

Tamoxifen

The first hormonal therapy developed for women with hormone-receptor-positive breast cancer was tamoxifen (Nolvadex), and tamoxifen is still the hormonal treatment of choice for premenopausal women. Tamoxifen is usually followed by treatments to stop the ovaries from producing estrogen. This includes both surgery to remove the ovaries or radiation to stop the ovaries from working. Some drugs can also stop the ovaries from working. These drugs include Zoladex (goserelin acetate), Lupron (leuprolide), or Trelstar (triptorelin).

Aromatase inhibitors

A different type of hormone therapy, aromatase inhibitors are approved for treatment of both early and advanced breast cancer and are now considered the standard of care for postmenopausal women with hormone-receptor-positive breast cancer. Aromatase inhibitors include:

Femara (letrozole)

Arimidex (anastrozole)

Aromasin (exemestane)

Estrogen receptor down-regulators

Estrogen receptor down-regulators are a form of hormone therapy in which a drug attaches itself directly to the estrogen receptor and destroys it. Over time, the cells make new estrogen receptors, but those cells will have fewer estrogen receptors and will be less responsive to the effects of estrogens. Currently, the only available estrogen receptor down-regulator is fulvestrant (Faslodex), which is given by monthly injection in a doctor''s office. Faslodex may be recommended for postmenopausal women with hormone-receptor-positive metastatic breast cancer after other hormonal treatments have stopped working.

Which Chemotherapy Drugs Are Used for Metastatic Breast Cancer?

Chemotherapy may be recommended to treat your advanced stage breast cancer if the cancer is hormone-receptor-negative, continues to grow after treatment with hormonal therapies or Herceptin (trastuzumab), or has spread to several other organs throughout the body such as the liver or lungs.

Essentially, chemotherapy drugs work by destroying rapidly dividing cells in the body, including cancer cells. Your doctor may recommend chemotherapy for your metastatic breast cancer if hormonal therapies are not appropriate or they are no longer controlling cancer growth.

For metastatic breast cancer, your oncologist may recommend one chemotherapy drug or a combination of several drugs, depending on your situation. Chemotherapy medications are divided into categories based on how they work, and they are often combined in a way that maximizes their effectiveness without increasing side effects.There are many chemotherapy drugs use to treat metastatic breast cancer. To minimize the side effects of chemotherapy, doctors typically use one chemotherapy drug before trying combinations. The most common single-drug chemotherapy drugs include:

Because there are so many different chemotherapy drugs and combinations, it’s important to talk with your doctor about which one or ones will work best for you. It’s also important to realize that just because you didn’t respond to one chemotherapy regimen doesn’t mean you won’t do better with another.

Which Biologic Treatments Are Used to Treat Metastatic Breast Cancer?

Biologic therapy is a whole new area of targeted cancer treatment. Biologics for cancer specifically target cancer cells and do not damage normal cells, thereby avoiding a lot of the side effects that come with more conventional chemotherapy.

Herceptin (trastuzumab) was one of the first biologic therapies used to treat breast cancer. Herceptin is a monoclonal antibody that specifically targets and stops the growth of cells that make too much of a protein called HER-2. About one out of every four breast cancers are HER-2-positive, and in women whose tumors test positive for the HER-2 protein, Herceptin has been shown in studies to lengthen survival in patients with metastatic breast cancer.

Herceptin is sometimes combined with hormone therapy in women whose breast tumors are hormone-receptor positive. Herceptin is given intravenously (directly into a vein) either alone or combined with chemotherapy, such as:

Paclitaxel (Taxol )

Carboplatin (Paraplatin)

Vinorelbine (Navelbine)

Xeloda (capecitabine)

Herceptin is not given in combination with Adriamycin (doxorubicin) because some women taking that combination experienced a higher risk of heart damage. Herceptin’s side effects tend to be mild, but as with all medications, you should talk with your doctor about any risks and benefits before beginning treatment.

Tykerb (lapatinib) is another HER-2 inhibitor that is used in combination with Xeloda (capecitabine) in patients with metastatic breast cancer who have previously been treated with Herceptin. Like Herceptin, Tykerb is a targeted therapy acting specifically on HER-2. But, unlike Herceptin, Tykerb is not a biologic and is given orally rather than intravenously.

Another biologic, Avastin (bevacizumab), is an antibody designed to inhibit a specific protein called vascular endothelial growth factor (VEGF).By working against VEGF, Avastin interferes with the blood supply to your tumor and keeps the tumor from growing and spreading. Avastin, in combination with Taxol (paclitaxel), is approved for the treatment of women who have not received chemotherapy for their metastatic HER-2-negative breast cancer.

Is It Possible to Live Well with Metastatic Breast Cancer?

Due to the many improvements in treatment, and the reduction in side effects from these treatments, many women with metastatic breast cancer are living longer active lives.

Side effects have not completely disappeared from the picture, however. Here are some tips for dealing with the most common side effects of treatment for metastatic breast cancer and for staying in good overall health while you’re getting treatment:

How to deal with side effects

Pain

Cancer that has spread often causes pain and discomfort throughout the body. Doctors have a variety of treatments to alleviate pain depending upon the location of the tumors, your symptoms and your tolerance for treatment. Typically, doctors try to relieve pain first by shrinking the tumor causing it with the use of hormone therapies, chemotherapy, targeted therapies and radiation. Pain-relieving medications may also be prescribed. Some patients find pain relief with complementary or alternative therapies, including meditation or relaxation training.

Fatigue

Fatigue is one of the most common long-term side effects of breast cancer treatment. One study found that fatigue may persist for years in cancer survivors, and women with cardiovascular problems, depressive symptoms, or those who were treated with combination therapies are even more likely to experience fatigue.

How to maintain overall health and well-being

Exercise

One of the best ways to combat many of the side effects from cancer treatment, including fatigue, is exercise. Research has shown that exercise routines that include aerobic activity and resistance training may alleviate some of the side effects associated with breast cancer and its treatment, including fatigue, depression and anxiety.

Nutrition

In additional to participating in regular exercise, it’s important for those living with cancer and undergoing cancer treatment to eat a healthy diet full of enough nutrients and calories to prevent nutritional deficiencies as a result of the cancer itself, or the side effects of common cancer treatments.

Common nutritional recommendations during cancer treatment include:

Eat enough calories to prevent weight loss

Eat more protein to prevent muscle wasting

Eat plenty of fresh fruits and vegetables

Eat several smaller meals throughout the day

Talk to your doctor about nutritional supplements that may be beneficial

Consider talking with a registered dietitian to design a personal food plan

Support

Often the most difficult aspect of living with advanced breast cancer is the uncertainty. To cope with the unknown, it’s helpful to work with your medical team, your family and friends to learn healthy ways to take care of yourself or ask for help when you need it.

Many women seek out additional support in the community or even online and find that sharing their concerns and learning from others who’ve shared their experience is one way to learn more, gain a sense of control and improve quality of life during cancer treatment.

Where Can I Get More Information on Metastatic Breast Cancer?

Your doctor may be able to refer you community resources and local cancer support groups. In addition, the following Web sites and organizations offer information and assistance for people living with breast cancer:

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